HomeMy WebLinkAboutP-13-588 M/ ,
S, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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�341�' CITY L MAN 1`[°—MII MA DATE 0?/OK)7C/3 PERMIT# /O
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JOBSITE ADDRESS LI kexcknAtor Tr 1 OWNER'S NAME
P OWNER ADDRESS , ' ' I TEL 6—C 3&2-357 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL Ir
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CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:LJ PLANS SUBMITTED: YES 0 NO❑
FIXTURES 1 FLOOR—. BSM 1 2 l 3 4 5 6 7 8 9 j 10 l 11 12 13 14
BATHTUB 4 i ,
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM _ 4
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM j ,
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN ,
FOOD DISPOSER I I
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK f
LAVATORY •! Iw.
ROOF DRAIN ,
Zj SHOWER STALL — I -�� �
O SERVICE/MOP SINK
TOILET - L
URINAL I •
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES m Is, _ _
WATER PIPINGI _
• OTHER I
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INSURANCE COVERAGE:
I have a current liability tnsurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES❑- NO ❑
\ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
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` 3 LIABILITY INSURANCE POLICY ID OTHER TYPE OF INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives,this requirement.
1V^/ CHECK 0 : OWN • 7 AG I
V J SIGNATURE OF OWNER OR AGENT
coereby certify that all of the details and information I have submitted or entered regarding this application are true coot to to the •,st of - ••wledge
• ,J and that all plumbing work and installations performed under the permit Issued for this application will be in compliance 11 Perti -nt•rovis oft 4 the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
o PLUMBER'S NAME STEPHEN A WINSLOW LICENSE# 12298 SIGN 7 URE
v MP El •- JP ' • CORPORATION0# 3281 PARTNERSHIP❑# LLC 0#
COMPANY NAME E.F.WINSLOW PLUMBING&HEATING CCS ADDRESS 8 REARDON CIRCLE 4 •
CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778
FAX 508-394.8256 CELL EMAIL ACCOUNTSPAYABLE@EFWINSLOW.COMn E rr+Y r� p pIf (2
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